Facilitators and barriers to care coordination in patient-centered medical homes (PCMHs) from coordinators' perspectives

Asia Friedman, Jenna Howard, Eric K. Shaw, Deborah J. Cohen, Laleh Shahidi, Jeanne M. Ferrante

Research output: Contribution to journalReview articlepeer-review

45 Scopus citations


Background: Care coordinators are increasingly featured in patient-centered medical home (PCMH) projects, yet little research examines how coordinators themselves define and experience their role. This is the first study describing experiences of care coordinators across the US from their own perspectives. Methods: This qualitative study used a 5-month private, online discussion forum to gather data from 25 care coordinators from PCMH practices representing diversity in practice size, setting, and type. Participants answered questions and interacted with one another, creating an online social learning collaborative while allowing for data collection for research. Results: Coordinators identified barriers and facilitators in their work at the organization/system level, the interpersonal level, and the individual level. Some factors emerged as both barriers and facilitators, including the functionality of clinical information technology; the availability of community resources; interactions with clinicians and other health care facilities; interactions with patients; and self-care practices for mental health and wellness. Colocation and full integration into practices were other key facilitators, whereas excessive case loads and data management responsibilities were felt to be important barriers. Conclusions: While all the barriers and facilitators were important to performing coordinators' roles, relationship building materialized as key to effective care coordination, whether with clinicians, patients, or outside organizations. We discuss implications for practice and provide suggestions for further research.

Original languageEnglish (US)
Pages (from-to)90-101
Number of pages12
JournalJournal of the American Board of Family Medicine
Issue number1
StatePublished - Jan 1 2016


  • Delivery of Health Care
  • Internet
  • Patient-centered Care
  • Primary Health Care
  • Qualitative Research

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health
  • Family Practice


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